BREATHITT COUNTY INTERVENTION SERVICES PLAN
GRADES K-5
Student Name: _______________________________________
Beginning Date: ______________
Review Date: __________
Grade: __________ DOB: ______________
Grade
Level
PRESCHOOL
SCREEN
score/100
Kindergarten
Readiness
DIBELS
Fall
Gray Oral
Spring
Fall
STAR
Spring
Fall
Spring
P
Student retained in
grade:
K
K
1
1
2
2
3
3
4
4
5
5
K-PREP (CRT/NRT)
Grade
Level
K
Reading
Math
Science
S.S.
THINKLINK
Writing
(KCAS)
P
Reading
A
B
C
P
Math
A
B
C
Science
A
B
C
A
S.S.
B
1
2
3
4
5
1
C
Detailed Explanation of Interventions
RtI Plan (Math and/or Reading)
Subject
ESS Plan
Specific skills to be
addressed:
Before School: ____
Strategies to be used:
After School: ____
Daytime: ____
Research-Based
Program/materials:
Summer Program: _____
Subject
Specific skills to be
addressed:
Strategies to be used:
Research-Based
Program/materials:
ST Math
Specific skills to be
addressed:
Strategies to be used:
Assessment Data
2
Save the Children
Date of Service
Specific skills to be
addressed:
Strategies to be used:
Assessment Data
Reading Recovery
Date of Service
School year
Strategies to be used:
Assessment Data
1st Grade Academy
Student enrolled in 1st grade academy
Student promoted from 1st grade academy
3
Grade
Level
Number of
Absences
1st semester
Number of
Absences
nd
2 semester
Classroom Performance
(Teacher comments)
K
1
2
3
4
5
4
Behavioral Plan
Student's Name: _______________________________ Teacher Name: __________________________________________
Date: ________________________________________
Please rate each behavior listed.
1
2
3
Never/Seldom
I. General Classroom Behaviors
Gets along with others while showing socially
appropriate behaviors.
Completes class assignments on time, applying
his/her best effort.
Speaks respectfully and complies with adult
requests without argument or complaint.
Remains focused on the teachers or the assignment
during class or work periods.
II. Physical Aggression
Treats others appropriately, and does not bully,
threaten, or intimidate them.
Avoids engaging in rough, physical ‘horse-play’
with other students.
Keeps hands to him/herself, not touching
classmates without permission.
Refrains from making physical threats against other
students.
Treats the property of other students with care and
respect.
Gets along with others while showing socially
appropriate behavior.
Avoids getting involved in physical fights.
Interacts with others without threatening the
physical safety of self or others.
III. Verbal Behaviors
Speaks respectfully and complies with adult
4
5
6
Sometimes
7
8
9
Usually/Always
Strategies to Address Behavior
5
requests without argument or complaint.
Is respectful of other students’ feelings and avoids
teasing them.
Takes responsibility for hi/her own mistakes or
misbehaviors and does not attempt to shift blame.
Is quiet during work or study periods, and does not
make noise or call out.
Waits to be called on or given permission to speak
before talking.
Uses only appropriate language in all settings, and
does not swear.
Waits his/her turn in discussions, and does not
interrupt others.
IV. Inattentive/Hyperactive Behaviors
Focuses attention on teacher instructions,
classroom lessons, and assigned work.
Thinks about the consequences of his/her actions
before acting.
Sits in class without fidgeting or squirming more
than peers.
Remembers academic instructions and directions
without needing extra reminders.
V. Socially Withdrawn Behaviors
Shows appropriate dependence in the classroom
and did not cling to adults.
Appears relaxed, with little sign of anxiety/fear of
being in school.
Is spontaneously included by peers in group
work/play situations.
VI. School Work-Related Behaviors
Is motivated to work on class assignments/projects.
Takes care with school assignments, avoiding
careless errors.
Completes assigned classwork and homework.
Other
6
Wright, Jim. Classroom Behavior Report Card Resource Book. <http://www.interventioncentral.org>
If the child is on medication, please answer the following questions:
Can you tell when the child is on medication or not? _________________________________________________________________
Does the medication work consistently throughout the day? ___________________________________________________________
Does the child appear to be on too much or too little medication? _______________________________________________________
Administrator Signature
Date
Comments:
Teacher(s) Signature
Date
Comments:
Parent Signature
Date
Comments:
Per KRS 158, 6453, KRS 158.6459, KRS 158.649, KRS 158.792, KRS RS 158.441, KRS 070, 704 KAR 3:305
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